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Post-Prostatectomy Radiation: Are Indications and PSA Thresholds Changing?
Alex Hennessey, MD, Ilene Staff, PhD, Peter Haddock, PhD, Max Jackson, BS, Joseph Tortora, BA, Alison Champagne, BA, Joseph Cusano, BS, Joseph R. Wagner, MD.
Hartford Hospital, Hartford, CT, USA.

BACKGROUND: The criteria for adjuvant (A) and salvage (S) post-prostatectomy radiotherapy (RT) continue to be debated. Given recent ASTRO/AUA guidelines recommending ART for patients with adverse pathologic features, and the availability of more sensitive PSA testing, we hypothesized that the characteristics of patients receiving post-prostatectomy RT is changing. As such, we examined the incidence of post-prostatectomy RT and the rate of secondary recurrences at our center.
METHODS: We retrospectively identified patients who underwent radical prostatectomy (RP) and subsequently received SRT or ART between Dec 1, 2003-Dec 31, 2013. Demographic, clinical, and pathological features were extracted. Patient cohorts were defined as either (i) ART: PSA <0.2, treatment within 1 year post-RP, (ii) Traditional SRT: PSA >0.2 prior to RT, or (iii) Modern SRT: rising PSA <0.2 and >1 year post-RP. The incidence and time to secondary recurrence were compared between each RT treatment group.
RESULTS: 3,570 patients underwent RP; 209 patients received post-RP RT (5.9%). 39 (18.7%), 30 (14.4%) and 140 (67.0%) underwent ART, modern SRT and traditional SRT. The incidence of ART and modern SRT significantly increased during 2008-2013 (p<0.001). Pathologic stage and margin rates were significantly different between groups, with ART being the highest. In line with our RT treatment definitions, the last PSA prior to RT was significantly different between groups (p<0.001). Overall, there was a significant difference in rates of second recurrences between groups (p=0.003), which remained significant in covariate analyses accounting for stage, PSA and Gleason score.
CONCLUSIONS: Conclusions In accordance with ASTRO/AUA guidelines, adjuvant RT is being given with increased frequency at our institution. Similarly, modern SRT is being given more often. We feel this is due to the advent of hypersensitive PSA. According to ASTRO/AUA guidelines, “data from retrospective and prospective trials tend to support the notion that more favorable biochemical outcomes are associated with very low PSA values at the time RT is offered.” Our study supports this as the secondary recurrence rate of modern SRT was significantly lower than traditional SRT (13.3% v 39.3%). Further study is needed to determine if ultrasensitive assays will result in improved outcomes for patients.


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